|Publication number||US7518502 B2|
|Application number||US 11/753,406|
|Publication date||Apr 14, 2009|
|Filing date||May 24, 2007|
|Priority date||May 24, 2007|
|Also published as||US20080030345|
|Publication number||11753406, 753406, US 7518502 B2, US 7518502B2, US-B2-7518502, US7518502 B2, US7518502B2|
|Inventors||Gene Edward Austin, Ralph W. Donati, Jr., Nicholas W. Granville, Mark E. Hulen, Sied W. Janna, Robert L. Morgan, James K. Rains, Randall Troutman, Darren J. Wilson|
|Original Assignee||Smith & Nephew, Inc.|
|Export Citation||BiBTeX, EndNote, RefMan|
|Patent Citations (94), Non-Patent Citations (4), Referenced by (68), Classifications (8), Legal Events (3)|
|External Links: USPTO, USPTO Assignment, Espacenet|
This application is a continuation-in-part of U.S. patent application Ser. No. 11/275,012 filed on Dec. 1, 2005, which claims priority to U.S. Provisional Patent Application No. 60/632,679 filed on Dec. 2, 2004. The entire contents of each disclosure are hereby incorporated by reference.
1. Field of the Invention
This invention relates to systems and methods for identifying, locating, and managing inventory of sterilized medical devices located within a sterilization case that is sealed with a wrap in preparation for a surgical procedure.
2. Related Art
Surgical procedures generally involve various sterilized instruments. Sterilization can occur by known techniques such as autoclaving or those utilizing substances such as ethylene oxide, vapor hydrogen peroxide, or ozone. Before sterilization, the surgical instruments are placed inside a sterilization case that is typically made from steel, aluminum, titanium, or plastic. A sterilization case also may be referred to as an instrument tray or instrument case. The sterilization case is then wrapped in a plastic sheet and sealed. The plastic normally allows particles, condensed water, water vapor, and other substances to leave the sterilization case but prevents foreign contaminants from entering the sterilization case. Upon completing the sterilization process, the sterilization case containing the medical instruments is still within the sealed wrap. Prior to the surgical procedure and in the sterile field of the operating room, the instruments are typically removed from the wrap and sterilization case, placed on a table, and counted to validate that all instruments needed for the particular surgical procedure are on the table.
The tracking and management of surgical instruments in hospitals, instrument management companies, and sterilization companies is important to the efficiency and safety of use of hand held medical or surgical instruments. Inventory tracking is difficult to manage given that the instruments pass through the purview of various parties in the supply chain. Most hospitals in the United States have from 3,000 to 5,000 different types of instruments which are organized into 300 to 600 different types of sets. The content of these sets changes frequently. Moreover, individual devices within these sets become damaged and then require repair or replacement. It is desirable to be able to identify an inventory of the medical instruments to facilitate repair and replacement of these instruments should they become broken or worn. Instruments also can be misplaced, which may remain unknown until the instruments are removed from the sterilization case and the wrap in the sterile field of the operating room prior to surgery. If one or more instruments needed for the surgery are missing, hospital personnel must open another sealed plastic wrap to retrieve the missing instruments or locate a replacement within the hospital. Considerable time is required searching the hospital for a replacement to obtain a complete set of necessary instruments, which often involves opening other sealed cases. In the meantime, a patient is under anesthetic in the operating theatre waiting to be treated at a cost of $100 per minute and can often be delayed by fifteen minutes whilst hospital staff search for missing instruments. Once the instruments are retrieved, the remaining instruments in the opened cases have to be re-sterilized. Many healthcare facilities do not have effective solutions in place for tracking and management of surgical instruments, which is likely to grow as more instruments are purchased from manufactures. However, there is an increasing trend towards healthcare companies providing additional value to hospitals by tracking the hospital's entire inventory and ensuring that instruments are in fact in the instrument tray.
Hospitals, instrument management companies, and sterilization companies often have difficulty tracking and managing surgical instruments as they pass through the purview of various parties in the supply chain. For instance, instruments are sometimes misplaced, which may remain unknown until the instruments are removed from the sterilization case and the wrap in the sterile field of the operating room prior to surgery. If one or more instruments needed for the surgery are missing, personnel must open another sealed plastic wrap to retrieve the missing instruments or locate a replacement within the hospital. Personnel associated with surgical preparation sometimes need to open several sealed cases before they obtain a complete set of necessary instruments or spend time searching the hospital or other facility for a replacement. Furthermore, the remaining instruments in the second sterilization case and those opened thereafter, even if not used in a surgical procedure, always must be sterilized again.
Tracking individual instruments to specific trays is very challenging because each individual instrument needs to be scanned to the tray to form a link between the instrument and the tray, which is a labor intensive process. The techniques used to track surgical instruments include manual counting, color-coding and memory devices, which are discussed in turn below.
Various methods of counting the surgical instruments are known but none are particularly efficient. Manual counting involves a skilled technician physically counting each instrument on the surgical instrument tray and then comparing the count result to an information sheet that provides an inventory list of instruments used in a particular surgery. This count is usually performed close to, but before, the scheduled surgery while the patient is either already on the surgical table or on their way to the surgical room. If there is a discrepancy between the count and inventory list, the person counting or their assistant must quickly determine which instrument is missing and where a suitable replacement may be located before the surgical procedure begins. This tracking technique is unreliable and labor intensive because significant time is required to count the instruments manually, determine if there is a discrepancy between the count and the inventory list, and locate a replacement instrument before the surgical procedure begins. This time is costly to both the instrument company and hospital and could needlessly delay surgery. In addition, there is a likelihood for human error in counting the instruments and comparing the count to the inventory list. Furthermore, the correct instruments for a particular surgical procedure may still be missing during surgery, forcing the surgeon to use a closely related, but incorrect, instrument to perform the procedure. Manually tracking medical instruments also requires that the surgical instruments be removed from the wrap and the sterilization case before they are counted and compared to the inventory list for discrepancies.
A less common approach to instrument tracking includes color-coding techniques to identify different surgical instruments. Others optically mark each instrument and later scan the instruments with a hand-held scanner that is connected to a data terminal to ascertain the history of that instrument. Such a method typically requires that the instrument be removed from the tray on arrival and scanned by humans, a method that is costly and time-consuming. In addition, colors can fade and a significant percentage of the population is color blind.
Other methods to count surgical instruments and compare to an inventory list involve electronic mechanisms. Data carriers such as memory devices are a more expensive alternative method for manually counting surgical instruments and comparing them to an inventory. Memory devices permit the linking of large amounts of data with an object or item. Memory devices typically include a memory and logic in the form of an integrated circuit and a mechanism for transmitting data to and/or from the device.
One such method utilizes an optical scanner, in communication with a computer and database, which reads an encoded optical pattern of a bar code attached to each surgical instrument. Individual surgical instruments may be identified by the encoded optical pattern of the attached bar code. The optical scanner usually converts the encoded optical pattern of a bar code into an electrical signal that represents an identification code associated in the database with a particular surgical instrument. The computer typically contains a memory with database information about each surgical instrument and correlates that information to the identification code. The computer may then be programmed to produce information to a user in a variety of formats useful in an inventory procedure.
An optical tag is one form of memory device, which relies on an optical signal to transmit data to and/or from the tag. The optical scanner converts the encoded optical pattern of a bar code into an electrical signal that represents an identification code associated in the database with a particular surgical instrument. Thus, individual surgical instruments may be identified by the encoded optical pattern of the attached bar code. There are a number of disadvantages to the use of optical tags. First, the size of a bar code is too large for placement on relatively small surgical instruments. Second, the time required to scan and inventory a group of medical instruments can be quite lengthy, which can needlessly delay a surgical procedure. Third, optical scanning techniques require the user to present the optical scanner in close proximity to and in the line of sight of the bar code on each surgical instrument and orient the scanning device appropriately to the bar code. Furthermore, each surgical instrument and attached bar code must be scanned individually. Finally, the optical scanning procedure is prone to human error. If the user does not orient the optical scanner correctly with respect to a bar code on a surgical instrument, the scanner could fail to read that item and it could be deemed missing when it is actually present in the surgical instrument group.
Another method for managing medical instrument locations prior to and during surgery utilizing electronic mechanisms involves attaching certain radio frequency identification (RFID) tags to surgical instruments and a reader that obtains information associated with the particular medical instrument through radio frequency. A second type of memory device is the radio frequency identification (RFID) tag, which typically includes a memory for storing data, an antenna, an RF transmitter and receiver or an RF transceiver to transmit data, and logic for controlling the various components of the memory device. RFID tags can either be passive or active devices. Active devices are self-powered, by a battery for example. Passive devices do not contain a discrete power source but derive their energy from an RF signal used to interrogate the RFID tag. A reader is used to obtain information associated with the particular medical instrument through radio frequency. The reader is in electrical communication with a computer system having a database of information about the inventory. After detecting the radio frequency signal from the RFID tag, the reader causes the computer system to change the data in the database to account for the presence of a particular inventory item. If each instrument was embedded with an RFID tag and the tray in which the instruments are placed is retrofitted with a RFID reader, instruments could be identified and logged the moment they are placed in the tray. RFID tags typically comprise an electronic circuit placed on small substrate materials. The electronic circuits contain encoded data and transmit or respond (actively or passively) with encoded or identifiable data as a radio frequency signal or a signature when an interrogation radio frequency signal causes the electronic circuit to transmit or respond (whether actively or passively). Some RFID tags are able to have their data modified by an encoded radio signal.
A reader is a radio frequency emitter/receiver or interrogator. In accordance with general RFID tag methodology, the reader interrogates RFID tags that are within its range by emitting radio frequency waves at a certain frequency. Each tag may respond to a unique set of interrogation frequencies. An RFID tag typically responds to an interrogation by emitting or responding with coded or identification information as a radio frequency signal or signature and this signal or signature (whether actively or passively) is detected by the reader. The reader is in electrical communication with a computer system having a database of information about the inventory. After detecting the radio frequency signal from the RFID tag, the reader causes the computer system to change the data in the database to account for the presence of a particular inventory item.
An RFID tag system has several advantages over manual counting and optical scanning systems. For instance, the RFID tag reader is not required to be aimed directly at a tag in order to detect a signal. An RFID tag system does not require the user to orient a reader with respect to a particular tag in order to obtain the information as the optical scanning system requires. An additional advantage of an RFID tag system is the capability of quickly performing an inventory of a large group of items by successively reading a tag associated with each item without requiring the user to perform multiple procedural steps. This saves time and expense relative to manual and optical scanning systems.
In theory, RFID tagging is an ideal solution for tagging individual instruments. However, it is also a very challenging proposition given current limitations with RFID technology. Any device attached to a medical device or surgical instrument must be capable of performing despite being attached to various metals. It is difficult to apply and read RFID tags on metallic alloys because they tend to either absorb or reflect RF signals. This is a problem because many surgical instruments and implants are metallic interfering with weak RF signals of either the reader or tag, thus reducing the system's read range. The sterilization case is also metallic preventing electromagnetic energy, such as a radio frequency signal, from entering or leaving the case. Thus, an RFID reader is unable to communicate with the RFID tags located inside the sterilization case and the instruments must be removed from the case, including breaking the sealed wrap, in order for the reader to determine the inventory of a particular group of instruments. If, after reading the removed medical instruments, the medical instrument group does not include an instrument necessary for the particular surgical procedure, hospital or medical instrument company representatives must break another sealed sterilization packet, remove the instruments from the case and read or interrogate the RFID tags of that group to find the instrument necessary to complete the first instrument group. This process includes high costs and time delays in preparing for a surgical procedure.
Tag reliability can be impacted by environmental factors such as humidity, radiation and temperature. Previously, commercial-off-the-shelf RFID tags could not withstand extreme temperatures without a temperature-resistant housing. For that reason, using them for items like surgical instruments which undergo an autoclave or dry heat sterilization cycle is complicated. Costs are presently very high for custom chips, and tags capable of surviving the temperatures in a sterilization cycle would have to pass very close to an RFID-reader.
Known RFID tag systems have been used to manage medical instrument locations prior to and during surgery. For instance, the individual instruments may be scanned prior to the surgery to ensure that all instruments needed for the procedure are present. Prior to completing the surgery, the surgical tray table may be scanned again to ensure that instruments are located on the tray table instead of inside the patient. Some RFID tag systems describe scanning the surgical cavity of the patient to check for the presence of any instruments prior to completing the surgery.
Previous and current RFID tag systems used to manage and inventory medical instruments require that surgical personnel break the sterilization seal of a group of instruments and remove the instruments from the packet before the reader reads medical instruments. This is because instruments are typically contained within a metallic sterilization case and the sterilization case prevents electromagnetic energy, such as a radio frequency signal, from entering or leaving the case. Thus, an RFID reader is unable to communicate with the RFID tags located inside the sterilization case and the instruments must be removed from the case, including breaking the sealed wrap, in order for the reader to determine the inventory of a particular group of instruments. If, after reading the removed medical instruments, the medical instrument group does not include an instrument necessary for the particular surgical procedure, hospital or medical instrument company representatives must break another sealed sterilization packet, remove the instruments from the case and read or interrogate the RFID tags of that group to find the instrument necessary to complete the first instrument group. This process includes high costs and time delays in preparing for a surgical procedure.
A medical instrument inventory and management system that allows personnel to read data regarding the individual medical instruments contained within a sealed sterilization case would decrease the time necessary to locate a particular instrument. In addition, determining the presence of particular medical instruments inside a sealed sterilization case could decrease the time and cost of preparing for a surgical procedure because breaking a second and additional sealed packets requires another cleaning, decontamination, and sterilization process. Furthermore, personnel could read the inventory of several packets and select the one with the correct instrument group for a particular medical procedure.
Further, there is a problem in locating missing instrument trays, implant trays, and devices. For example, a tray may be lost at a hospital and hospital personnel are not able to locate the tray in time for surgery. Another example would be the tray lost in delivery or sent to an incorrect facility.
Sometimes a surgeon does not know how to use an instrument correctly or know what the next step is in a complicated surgical procedure. An example may be a resident using an implant system in the middle of the night and not knowing whether to perform step A or step B in the surgical procedure.
Hospitals face significant costs in managing inventory. Currently, a sales representative must review the inventory and determine if the hospital has an adequate amount of each product. If the sales representative determines that inventory is low, then the sales representative places an order to replenish the stock.
It would be of significant benefit if the instrument trays and surgical instrument inventory could be tracked. Tracking assets, physical inventory, and other objects in a large-scale enterprise is a daunting task. Traditionally, this requires a manual, physical inventory that must be regularly repeated. Further, as assets move from place to place, or out of the control of the enterprise, the conventional process requires a time-intensive paperwork trail to track the movement of the assets.
This already-daunting task is made even more difficult when the assets being tracked are physically similar because in that case every specific serial number must be verified to conclusively identify the specific item.
Recently, for items such as shipping containers, RFID tags have been used to partially automate this process in a real-time location system (RTLS). In the common case, an asset with an attached RFID tag transmits a unique identifier, allowing an RFID tag reader to easily receive the transmitted ID number and thereby identify specific shipping containers.
An entirely different type of asset location is used for locating stolen vehicles. A commonly known system of this type is the “LoJack” system manufactured by the LoJack Corporation of Westwood, Mass., and described in U.S. Pat. Nos. 4,818,998, 4,908,629, 5,917,423, and 6,665,613, all of which are hereby incorporated by reference. In general terms, this type of system uses a remotely activated system to track a vehicle in motion, using transceivers installed in the target vehicle in combination with transceiver/detectors mounted on other vehicles. Typically, a LoJack system is used to track stolen vehicles. When a target vehicle is reported stolen, its transceiver is remotely activated, and thereafter police units that are specially equipped with transceiver/detectors can detect and locate the target vehicle.
LoJack is a form of an asset location system that utilizes a special FCC-allocated radio frequency (173.075 MHz), an older technology, very high frequency (VHF) signal. The LoJack transceiver is passive until activated by police radio towers, and specially equipped police cruisers with receivers must work together to triangulate and locate the target vehicle. LoJack does not utilize global positioning satellites (GPS) for location information.
Another type of long-range vehicle-tracking system uses GPS to identify the current location of a vehicle. In this case, a GPS receiver is mounted in the vehicle to determine the vehicle location, and a separate transmitter is used to send the location data to the person or entity tracking the vehicle. In the common ONSTAR system, cellular telephone technology is used to activate the GPS receiver and to transmit the location data to the ONSTAR service center. ONSTAR is a registered trademark of OnStar Corporation of Troy, Mich.
Goods shipped to a destination from a manufacturing plant, warehouse or port of entry are normally tracked to assure their timely and safe delivery. Tracking has heretofore been accomplished in part by use of various shipping documents and negotiable instruments, some of which travel with the goods and others of which are transmitted by post or courier to a receiving destination. This paper tracking provides a record which is completed only on the safe delivery and acceptance of the goods. However, there sometimes is a need to know the location of the goods prior to delivery or acceptance. Knowledge of the location of goods can be used for inventory control, scheduling and monitoring.
Shippers and/or distributors have provided information on the location of goods by tracking their vehicles and knowing what goods are loaded on those vehicles. Goods are often loaded aboard shipping containers or container trucks, for example, which are in turn loaded aboard railcars. Various devices have been used to track such vehicles. In the case of railcars, passive radio frequency transponders mounted on the cars have been used to facilitate interrogation of each car as it passes a way station and supply the car's identification. This information is then transmitted by a radiated signal or land line to a central station which tracks the locations of cars. This technique, however, is deficient in that whenever a particular railcar remains on a siding for an extended period of time, it does not pass a way station. Moreover, way station installations are expensive, requiting a compromise that results in way stations being installed at varying distances, depending on the track layout. Thus, the precision of location information varies from place to place on the railroad.
Recently, mobile tracking units have been used for tracking various types of vehicles, such as trains. Communication has been provided through the use of cellular mobile telephone or RF radio link. Such mobile tracking units are generally installed aboard the locomotive which provides a ready source of power. However, in the case of shipping containers, container truck trailers and railcars, a similar source of power is not readily available. Mobile tracking units which might be attached to containers and vehicles must be power efficient in order to provide reliable and economical operation. Typically, a mobile tracking unit includes a navigation set, such as a GPS receiver or other suitable navigation set, responsive to navigation signals transmitted by a set of navigation stations which may be either space-based or earth-based. In each case, the navigation set is capable of providing data indicative of the vehicle location based on the navigation signals. In addition, the tracking unit may include a suitable electromagnetic emitter for transmitting to a remote location the vehicle's location data and other data acquired from sensing elements on board the vehicle. Current methods of asset localization require that each item tracked be individually equipped with hardware which determines and reports location to a central station. In this way, a tracked asset is completely “ignorant” of other assets being shipped or their possible relation to itself. In reporting to the central station, such system requires a bandwidth which scales approximately with the number of assets being reported. The aggregate power consumption over an entire such system also scales with the number of assets tracked. Further, because both the navigation set and the emitter are devices which, when energized, generally require a large portion of the overall electrical power consumed by the mobile tracking unit, it is desirable to control the respective rates at which such devices are respectively activated and limit their respective duty cycles so as to minimize the overall power consumption of the mobile tracking unit.
Most present-day asset tracking systems are land-based systems wherein a radio unit on the asset transmits information to wayside stations of a fixed network, such as the public land mobile radio network or a cellular network. These networks do not have ubiquitous coverage, and the asset tracking units are expensive. A satellite-based truck tracking system developed by Qualcomm Inc., known as OMNITRACS, is in operation in the United States and Canada. This system requires a specialized directional antenna and considerable power for operation, while vehicle location, derived from two satellites, is obtained to an accuracy of about one-fourth kilometer. U.S. Pat. No. 5,129,605 to Burns et al., incorporated by reference herein, describes a rail vehicle positioning system for installation on the locomotive of a train and which uses, to provide input signals for generating a location report, a GPS receiver, a wheel tachometer, transponders, and manual inputs from the locomotive engineer.
In an asset tracking system disclosed in U.S. Pat. No. 5,651,800, entitled “Local Communication Network for Power Reduction and Enhanced Reliability in a Multiple Node Tracking System” by Welles et al. and in U.S. Pat. No. 5,588,005 entitled “Protocol and Mechanism for Primary and Mutter Mode Communication for Asset Tracking” by Ali et al., both of which are incorporated herein by reference, a tracking system based on a “mutter” mode local area network is used to generate data that is transmitted to a central station. In this asset tracking system, there are two modes of communication. One mode is communication between the central station and the tracking units, which is usually via satellite. The second mode is a local area network, referred to as the “mutter” mode, between tracking units. One of the tracking units, denoted the master unit, communicates with the central station.
One of the chief challenges in using the first mode of communication is to devise a protocol for the communications that will provide efficient use of the communication facilities and respect the special sensitivities of the reporting scenario. Such protocol should meet the following guidelines:
1. The protocol should be two-way, thereby supporting transmission to and from a central station.
2. The protocol must accommodate a large number of assets and be scalable so that assets can be added and deleted without impacting normal service.
3. The protocol must accommodate variable length messages. The variable length may arise from a number of considerations; for example, the individual asset may have extra sensor data to report in addition to its location.
4. The protocol must have a chatter suppression feature to allow selective turn-off of a specific malfunctioning asset's transmitter.
5. The protocol must function efficiently if used over an extremely long path such as is implied by use of a geostationary satellite.
6. The protocol must allow encryption or a privacy feature to be added later without significantly impacting the capacity.
7. The protocol must be sufficiently robust to allow an asset to enter the system at any time without knowledge that cannot be gleaned following its entry into the system, and must tolerate occasional transmission errors and not be unstable but degrade gracefully under additional load.
8. The protocol must not require the assets to be receiving all the time but accommodate a duty cycle significantly less than 100% for periods of monitoring communication frequencies.
The protocol must be designed to be easily adjusted and nominally reprogrammable to allow presentation of its efficiency as the operational scenario matures.
The term “telematics” is often used to refer to automobile based asset tracking systems that combine GPS satellite tracking and wireless communications for automatic roadside assistance and remote diagnostics.
Typically, an asset tracking device or module is installed in the vehicle to be tracked. The location of the device is determined by the telematics system 100 using a positioning technology 150, such as GPS or time difference of arrival (“TDOA”). The location information is then provided to an application to service a customer.
Briefly, the GPS was developed by the U.S. Department of Defense and gradually placed into service throughout the 1980s. The GPS satellites constantly transmit radio signals in L-Band frequency using spread spectrum techniques. The transmitted radio signals carry pseudorandom sequences which allow users to determine location on the surface of the earth (within approximately 100 feet), velocity (within about 0.1 MPH), and precise time information. GPS is a particularly attractive navigation system to employ, being that the respective orbits of the GPS satellites are chosen so as to provide world-wide coverage and being that such highly-accurate radio signals are provided free of charge to users by the U.S. government. The main problem with current GPS technology is the requirement for an unobstructed view of the sky for communication with GPS satellites. Its advantage is that is can provide a location anywhere in the world without any additional infrastructure on the ground. Improved receiver performance and signal processing and new technologies, like “Enhanced GPS,” will provide locations where traditional GPS would fail.
On the other hand, TDOA uses the existing cellular network infrastructure to determine location. Referring to
The communications networks 130 for linking tracking devices to platforms 120 to provide services 110 to customers include cellular and telephone networks. With respect to cellular networks, network providers typically make use of the Advanced Mobile Phone System (“AMPS”) control channel frequencies for the transfer of small data packets. The use of the cellular network control channel provides more robust communication than cellular voice traffic so that it is possible to communicate with devices located in places where ordinary cell phones have marginal or intermittent voice coverage. Clients of these virtual carriers can make use of a TCP/IP data link to connect their operations centre to the virtual carrier network which then provides continent wide coverage through cellular service providers.
For example, in U.S. Pat. No. 6,131,067, to Girerd, et al, a client-server based system is described in which the location of a tracking device is determined using GPS information. This location is then reported to a user via the Internet. The entire disclosure of U.S. Pat. No. 6,131,067 is hereby incorporated by reference.
It would be of significant benefit if existing telematics systems could be adapted for tracking medical devices and/or sterilization cases. Medical devices may include medical implants, medical instruments, and other components.
There is a need in the art for a system and method for locating missing sterilization cases and/or medical devices. Further, there is a need in the art for a system that provides instruction to medical personnel on how to perform certain procedures or how to use certain medical instruments. Finally, there is a need for continued improvement in the area of hospital inventory management.
In one aspect of the invention, there is provided a system for tracking one or more surgical assets. As examples, the surgical asset may be a sterilization case, a medical instrument tray, a medical instrument, or a medical implant. The system includes a first receiver, a processor, a first long-range transmitter, a global positioning satellite reader, a medical device readiness sensor, a second long-range transmitter, and a storage device. The first receiver receives a signal from a short-range transmitter. The signal contains localized location information corresponding to the surgical asset. The processor determines if the localized location information corresponding to the surgical asset has been received. The first long-range transmitter requests location information of the surgical asset. The global positioning satellite reader is operatively connected to the surgical asset, and the global positioning satellite reader is adapted to provide localized location information. The medical device readiness sensor is configured to provide readiness data. The second long-range transmitter is operatively connected to the medical device and is electrically connected to the global positioning satellite reader, the second transmitter is configured to transmit localized location information obtained from the global positioning satellite reader. The storage device electronically stores the localized location information and the readiness data.
The short-range transmitter may utilize radio frequency transmission. Similarly, the first long-range transmitter and the second long-range transmitter may utilize microwave transmission.
In one embodiment, at least one of the first long-range transmitter and the second long-range transmitter form a portion of a wireless telephone network.
In one particular embodiment, the surgical asset is a sealed sterilization case adapted to allow radio frequency signals to pass through at least one side of the case. This embodiment includes: at least one radio frequency identification tag; at least one medical instrument contained in the sealed sterilization case and attached to the radio frequency identification tag; and a reader adapted to obtain information, via radio frequency, from said radio frequency identification tag. The sterilization case may have at least one surface that has at least one opening adapted in size or shape to allow radio frequency signals to enter and leave the case. Further, the sterilization case may be composed of a material that is configured to allow radio frequency signals to enter and leave the case. The radio frequency identification tag associated with the instrument may be embedded inside the instrument or attached on the outside surface of the medical instrument. The radio frequency identification tags may be passive or active.
In some embodiments, the reader is electrically connected to a microprocessor and may be in wireless communication with the microprocessor.
In another aspect of the invention, there is provided a method of tracking at least one surgical asset. The method includes the steps of: (a) detecting if localized location information corresponding to the surgical asset has been received, the localized location information corresponding to a location determined from a signal received from a short-range transmitter; (b) if the localized location information has been received, then storing the localized location information; (c) if no localized location information has been received for a predetermined amount of time, then sending a location request; (d) receiving secondary location information corresponding to the surgical asset, the secondary location information corresponding to a location determined from global positioning satellites; (e) detecting if the surgical asset is ready for use; and (f) storing the secondary location information.
In another aspect of the invention, there is provided a system for tracking at least one surgical asset. The system includes an electronic component, a location module, a power module, a communication module, an antenna module, and a medical device readiness module. The electronic component includes a processor module and is operatively connected to the surgical asset. The location module is electrically connected to the processor module and includes a global positioning satellite reader. The power module and the communication module are electrically connected to the processor module. The communication module has a short-range receiver and a long-range receiver. The antenna module and the medical device readiness module are also connected to the power module.
In yet another aspect of the invention, there is provided a method for retrieving surgical information corresponding to a surgical asset. The method includes the steps of: (a) detecting the surgical asset; (b) identifying the surgical asset; (c) retrieving a stored file corresponding to the identified surgical asset; and (d) executing the stored filed.
The advantage of being able to determine if all needed instruments or implants are present in a tray is that it allows the user to perform this task pre-operatively allowing time for the device to be located or replaced before it is needed in surgery. Also, it helps someone who is not intimate with the system know if the missing instrument(s) or implant(s) in the tray is needed for the surgery or not. Often there are spots made available in the set for a rarely used instrument, and a novice user may notice this unfilled space and order a replacement part. This invention eliminates such scenarios by informing the user that as to whether all necessary instruments to perform the surgery are present in the set.
The advantage of being able to track the whereabouts of an instrument, implant, or set within an area such as a hospital is that it prevents surgeries having to be slowed or delayed due to not being able to locate for example a needed instrument. Being able to locate a misplaced instrument helps prevent the user from trying to find a needle in a hay stack, and also cuts down on parts that are unnecessarily re-ordered because an instrument in misplaced.
In one aspect of the invention, there is provided an electronic instrument tray which allows personnel to determine whether there are any individual medical instruments missing within a sealed sterilization case. This is achieved using electrical circuits which are contained within the tray. A method of determining the status of the circuit is displayed either on the outside of the tray or on a hand held device or computer. The tray does not need to be opened for the circuit to work or to discover its status. In the simplest form, the circuit detects whether the tray contains a complete set or not. The solution described herein could accommodate plastic trials and instruments where current flow cannot be achieved with non-conducting materials. The housing may be adapted so that electrical contact is made by adding switches which are activated when the instrument is located in its housing. More complex versions identify which instruments are missing. For example, the system is capable of identifying the individual medical instruments inside a sealed sterilization based on the unique electrical resistance associated with its own particular instrument which may be displayed on a screen. The word ‘instrument’ could be replaced by the phrase ‘implant or implant component’, and a similar device could determine whether all components of an implant are present in an implant tray. Powering the electrical circuits can be provided either internally using a sterilizable internal battery or external device inserted into the case when inventory is required.
Further areas of applicability of the present invention will become apparent from the detailed description provided hereinafter. It should be understood that the detailed description and specific examples, while indicating the preferred embodiment of the invention, are intended for purposes of illustration only and are not intended to limit the scope of the invention.
The present invention will become more fully understood from the detailed description and the accompanying drawings, wherein:
The following description of the preferred embodiment(s) is merely exemplary in nature and is in no way intended to limit the invention, its application, or uses.
GPS antenna 22 sends the most recent GPS signal to GPS chipset 30, which in turn passes the latest valid position reading to processor module 20. In the depicted embodiment, motion sensor 32 is always active and is connected to gyro 34 and speed calculator 36. The received GPS reading is constantly checked for validity. Motion sensor 32 determines if system 10 needs to “wake up” or can remain in the sleep mode. Gyro 34 derives the motion of system 10 in three dimensions. Speed calculator 36 estimates the acceleration and deceleration at any given moment. The position information derived from gyro 34 and speed calculator 36 is processed internally for position calculation. The data flow in location module 12 is depicted in
Internally, the location of system 10 is expressed with the geographical coordinate system in conventional longitude and latitude readings. The initial location of system 10 is set when system 10 is ready to deploy, using either (1) a GPS data entry, (2) a location initialization input device, or (3) a manual position entry. Any one of the three processes is sufficient to initialize the location of system 10.
Consider first GPS entry. The initial location can be set with the built-in GPS engine board 30. One only needs to take system 10 outdoors for a few seconds, and system 10 initializes its GPS position by itself. The GPS position is then stored in the memory. This method is most convenient as it only requires direct exposure to GPS satellites. This is diagrammatically illustrated in
Consider now the use of the location input routine. One can initialize the position using a simple data entry device, such as a personal computer, a laptop computer, a handheld computer, a personal data assistant (PDA), or any other device that can send a position signal through a serial port, infrared port, USB port, network connector, or any communication port to allow for automatic or manual entry of position information. This method is most useful when a large number of devices are to be initialized, such as at the manufacturer's site. The longitude and latitude readings are known and stored in a simple utility program. As soon as system 10 is connected to the external data entry device (not shown) at step 42, the location is automatically stored in the memory and the initial position of system 10 is initialized.
In a similar manner, a third way of initializing the location is to enter the longitude and latitude of the current position manually at step 42 using any external device through a serial port, infrared port, USB port, network connector, or any such device to allow for manual entry of the location. This mechanism ensures that system 10 can be used after being dormant for a long period of time and the current location can be re-initialized whenever necessary.
Once initialized, the location information is kept in processor module 20. The initial location will be changed along with the movement of system 10. As soon as system 10 is moved, the current location reading becomes different from the initial location.
GPS antenna 22 always passes the GPS signals to the GPS chipset 30. Each GPS signal is evaluated for validity at step 38. If the latest GPS reading is valid, both the updated current position and the time stamp when the signal is received are passed to processor module 20 at step 40 for storage and real-time retrieval. If the latest GPS is not valid, a position calculation based on the motion sensor is activated at step 32′. On the right-hand side of
Using a motion detector to dynamically adjust location information is subject to errors at different steps of the computation. In general, the errors are small and random for each computation. Thus, over a long period of time, the individual errors may balance out among themselves or the cumulative error may accumulate over time. In any case, it is always helpful to correct the location reading whenever a GPS reading becomes available. When system 10 is inside a building, tunnel, parking structure, or a narrow valley, for example, a valid GPS may not be available. In this case, the current position of system 10 is adjusted though the motion detector. Whenever a valid GPS reading becomes available, the current location is automatically corrected at step 44.
GPS correction may take place even when system 10 is not directly exposed to GPS satellites. When GPS antenna 22 is in the direct line of sight of GPS satellites, the signals are most reliable and accurate. An additional mechanism is automatically activated when no direct GPS readings are available. The indirect GPS reading may be obtained from either reflected or re-radiated satellite signals. Although the reflected or re-radiated GPS signals do not provide the same level of positional accuracy as direct line readings, they nonetheless provide enough accuracy within a 20-meter range. In the future, a major public structure may be installed with a GPS receiver that re-radiates GPS signals to the neighborhood. Additionally, some structures, such as a hospital, may re-radiate the signal internally. System 10 will then be able to detect such re-radiated GPS signals and correct the position automatically.
Another way of correcting GPS position is through an RF connection wherever localized position information is broadcast from a station. Different modes of position information can be transmitted for short-range communication applications. As an example, designated short-range wireless communication frequencies, such as such as ZIGBEE™ or BLUETOOTH™, may be used for broadcasting localized position information within a hospital or other healthcare facility. ZigBee is a published specification set of high level communication protocols designed for wireless personal area networks (WPANs). The ZIGBEE trademark is owned by ZigBee Alliance Corp., 2400 Camino Ramon, Suite 375, San Ramon, Calif., U.S.A. 94583. Bluetooth is a technical industry standard that facilitates short range communication between wireless devices. The BLUETOOTH trademark is owned by Bluetooth Sig, Inc., 500 108th Avenue NE, Suite 250, Bellevue Wash., U.S.A. 98004. Another possible implementation in the future is the use of RF among public agencies to continuously broadcast position information to any mobile receivers capable of interpreting the code. When either a Bluetooth-based network or a local RF network is implemented for position information, and the designated frequency and interpretation code are made available to the public, system 10 is able to correct its GPS position accordingly. Because the accuracy of such local position information is not as accurate as GPS, GPS data will always override any position calculation based on reflected GPS, re-radiated GPS, or localized position information through Bluetooth or other localized RF systems.
Communication module 14 is designed to manage communication continuously and uninterruptedly between system 10 and a known central facility at a remote site, and to ensure that the current location of system 10 is always available at the central facility. Given that no existing terrestrial communication network provides global coverage, module 14 must be built on a scalable, multi-platform architecture to ensure uninterrupted global communication.
Communication module 14 comprises three components as shown diagrammatically in
Communication module 14 detects the availability of a wireless communication mode and establishes the connection whenever needed through the use of communication detector 52. It always checks the availability of any local RF as this is the least expensive mode. If a local RF connection cannot be made, it opens the digital cellular channels and detects from the list of priority any existing channel for communications.
The processing taking place in communication module 14 is to establish a multi-band, digital cellular connection as depicted in
If a surgical asset, such as an instrument tray or surgical instrument, is to be transported within a predefined geographical area and a local RF communication network is available within the area, such as tracking the instrument tray within a hospital or other healthcare facility, communication through the local RF network might be most effective and least expensive. System 10 allows the user to take advantage of the available RF communications for the most cost-effective tracking. Due to the fact that local RF networks vary in frequency, system 10 uses a scalable RF modem so that the communication can be adjusted whenever necessary. In some embodiments, this mode, if available, is the first choice of communication for system 10. The localized RF network is activated only when system 10 is to be tracked within a specific geographical region.
The RF capability serves another important function in receiving GPS location through a transporter, instead of directly from the GPS satellites. This is possible when system 10 is attached to a container on a ship, located inside a building, stored in a warehouse, located within a vehicle or in any other enclosed structure where directly receiving GPS signals is not possible. If the vehicle, ship, building, warehouse, or other enclosed structure has an external GPS receiver and the receiver broadcasts the GPS location through an RF channel, the position information is received and the current location is updated accordingly. This introduces an additional mechanism to ensure the accuracy of location information.
For medical device tracking, the same idea applies in the situation where the vehicle is already installed with a GPS antenna mounted on the exterior. System 10 detects the GPS signals transmitted through a short-range local area network component and receives the position information directly. In this case, system 10 can be a portable device by itself or attached to any device, such as a PDA or a mobile data computer.
Alternatively, the vehicle is equipped with an external GPS antenna that receives GPS signals, and the system 10 is electrically connected to the external antenna.
Whenever the communication is on satellite, the communication module will continue to search for RF and cellular connection. As soon as either a local RF network is found, or a cellular network can be connected, the satellite connection is dropped and the communication re-established.
If a local RF network is not available for the tracking system or the surgical asset tends to be transported over a wide geographical area, a second communication mode can be made through a commercial cellular network, or wireless digital network, such as CDPD, CDMA, AMPS, GSM, Mobitex, etc. These networks tend to offer extensive coverage, although in most cases no single network offers complete worldwide coverage.
Communication module 14 utilizes an adjustable multi-band radio modem 48 so that it does not rely on any one single network to provide communication capability. A built-in sensor detects the availability of each network and establishes communication with the available network.
Communication module 14 requires a specifically designed integrated circuit board with the following processing capabilities. First, a system-setup mechanism allows the user to input as parameters (1) the frequency range, (2) the protocol, and (3) the priority level for each cellular network to be incorporated at steps 62, 64 as shown in
Commercial cellular communication networks and wireless data networks suffer from their inability to provide complete global coverage. Over vast areas of deserts, forests, and oceans, one can utilize any one of the available long-range radio communication technologies. Among the available long-range radio communication technologies, satellite communications are most reliable and efficient. Communication module 14 is equipped with a satellite communication modem 46 to transmit and receive signals through communication satellites.
The use of satellite communication is required only when no other communication system is available. When detector 52 cannot establish communication through local RF radio networks, cellular networks, or wireless data networks, it activates satellite modem 46 to ensure non-interrupted communication with the central facility. The satellite communication is automatically terminated if another mode of wireless communications is established. In other embodiments, the system attempts to make contact through the use of a pager network.
Due to the durability requirements of tracking surgical assets, system 10 is able to function continuously for an extensive period of time. In one particular embodiment, system 10 is able to operate for a minimum of one year without external recharging. Requirements for duration longer than one year can be achieved by enhancing power module 16. To achieve the objective of long durability, power module 16 utilizes an innovative power management mechanism to minimize the use of power while recharging the battery whenever possible. In particular, power module 16 is configured to switch between a sleep mode when the system 10 is stationary and a wakeup mode when the system 10 is moving.
Power module 16 comprises four components as diagrammatically depicted in
The system wakeup unit 80 plays an important role in energy conservation. Unit 80 is adapted to maximize the duration of system 10 by minimizing the use of battery power. Unit 80 controls system 10 in such a way that whenever system 10 does not need to stay live, it shuts down all the components of system 10 that need not function and keeps system 10 in a sleep mode. When system 10 is in the sleep mode, only key sensors that consume the minimum amount of energy are kept active.
System wakeup sensor 80 is connected to the speed sensor 36 in the location module 12. When system 10 is not moving, speed sensor 36 remains active. When system 10 starts to move again, speed sensor 36 issues a signal to trigger system wakeup unit 80 to start functioning. In an alternative embodiment, when system 10 stops moving or comes to rest for a short period of time, speed sensor 36 issues a signal to trigger system wakeup unit 80 to start functioning.
In addition to speed sensor 36, system wakeup unit 80 is also equipped with an optional data receive sensor 88 connecting to communication module 14. Data receive sensor 88 is identical to that installed in commercial pagers and it consumes minimum energy when no communication is taking place. Data receive sensor 88 makes it possible for the central facility to activate system 10 remotely for any reason. In principle, system 10 stays dormant if it is not moving, and during the period when system 10 remains dormant, the central facility already has the current location through the last transmission, no matter how long ago it was recorded. Data receive sensor 88 allows the central facility to issue a system wakeup command and receive a current report of the location, just to make sure system 10 remains functional. In most cases, the optional data receive sensor 88 is used for system testing.
A non-leaking, high energy-density battery 82, such as a specially designed lithium polymer battery or a more commonly used lithium ion battery, or any other battery that enhances the energy efficiency, may be included in system 10. Given the current battery technology and the system's effective mechanism for minimization of energy use through the control in power module 16, a power unit 82 of compact size can sustain system 10 over an entire year without the need for recharging, if system 10 stays dormant or if the communication between system 10 and the central facility is maintained at a relatively low level. Battery 82 is recharged automatically through an external AC adapter 86 and the built-in recharging unit 84.
Recharging unit 84 is implemented with any single or multiple recharging source available, depending on the use of system 10, including an external recharging source 92, an optional internal recharging source 90, and a solar power source 94. With any one or more of the recharging components are implemented, battery 82 is recharged whenever any of such components works.
The external mechanical recharging source 92 allows system 10 to be attached to any external mechanical power source, such as a windmill, a hand crank, or a motion powered piezoelectric generator. For the wind-powered recharging unit 84, the system 10 has four openings on the corners to allow for air to flow through. In each opening, a wind-driven propeller (not shown) rotates whenever air flows through. As the system 10 is attached to the surface of a container, for instance, and as the container moves during shipping, the four propellers automatically recharge power unit 16. The internal mechanical recharging source 90 uses any equipment that generates electricity whenever system 10 moves. For instance, a pendulum pulling a thin-wire spring in the internal recharging source 90 when system 10 moves may recharge battery 82 accordingly with a trickle charge. The solar recharging source connects a charging mechanism to the solar panel 94 on the surface of system 10. If system 10 is installed on the surface and receives sunshine, it automatically generates energy and passes the energy to recharging unit 84. System 10 also may utilize or incorporate an inductive charger.
Recharging unit 84 is designed to prolong the duration of system 10 over an extensive period of time. As long as recharging unit 84 remains functional, the system 10 will continue to operate without limitation.
The AC adapter 86 is installed for recharging battery 82 whenever an AC power source becomes available. Even though system 10 may be running on battery 82 for an extensive period, any time the chance arises, recharging from the external power source will ensure the maximum recharging of battery 82.
Thus, it can be appreciated that as shown in
As diagrammatically depicted in
Antenna module 18 as shown in
GPS antenna 22 receives satellite signals from the GPS constellation. If GPS signals are strong enough to get the position, the data will be used to update the location of system 10. GPS antenna 22 is usually mounted on the top cover of the shipping container, instrument tray case, or tracked object to maximize its exposure to GPS satellites. If system 10 is mounted on the side, then antenna 22 is moved to the side of the shipping container, instrument tray case, or tracked object wherever most appropriate.
System 10 may be attached to an instrument tray within a vehicle, a container on a ship, stored inside a warehouse, located within a building, or in any enclosed structure where GPS signals cannot be received directly. In such cases, if the vehicle, ship, warehouse, building, or other structure has installed an external GPS and reradiate the GPS signals to any GPS receivers within the structure, the GPS antenna can continue to receive the accurate position and update the location of system 10. This ensures that even when system 10 is not moving by itself, it still can update its location.
RF antenna 24 can be mounted on the side of system 10 of the shipping container, instrument tray case, or tracked object. Antenna 24 is to be used for communications with the available RF channel. Antenna 24 is adjustable for different frequencies of communication. For instance, when the system is installed in a hospital or other healthcare facility, RF antenna 24 must be adjusted to maximize the communication through the specific channel.
Antennas 26 for the multi-band terrestrial communications through either the commercial cellular networks, or wireless digital networks, can be mounted on the top or any side of system 10 of the shipping container, instrument tray case, or tracked object, depending on how system 10 is to be attached to the surgical asset.
Antenna 28 for satellite communication is also mounted on the top of system 10, depending on how system 10 is to be attached to the asset.
Thus, in summary, it can be appreciated that the surface of the system is covered with four sets of antennas controlled by an integrated circuit board, GPS antenna 22, antenna 24 for local RF, antenna(s) 26 for cellular networks, and antenna 28 for satellite communications. GPS antenna 22 constantly detects and receives GPS signals, both directly from the GPS satellites if the surface is exposed to the sky, and indirectly from reflected signals and re-radiated signals. The received GPS signals are evaluated for validity in the location module 12. Local RF, cellular networks, and satellite antenna are all connected to the communication module 14. The exchange of location information received from GPS antenna 22 and the wireless communications through any of the existing mode takes place in the processor module 20.
Processor module 20 as shown in
A power control interface 104 couples CPU 100 with power module 16. When speed sensor 36 indicates no movement of system 10, all the components in system 10 are shut down except for two sensors, speed sensor 36 and system wakeup sensor 80. If speed sensor 36 detects motion of system 10, location module 12 is activated to update the position using either the GPS reading, if GPS is valid, or to receive the current location information that is broadcast through the RF, if such system is available. Otherwise, motion sensor 32 is used to calculate the current location from the three dimensional gyro 34 and speed sensor 36. Whenever the speed drops to zero, the system 10 returns to the dormant stage at step 98, shown in
Battery recharging is activated automatically. If the external AC power source is connected, then the battery is recharged automatically. If any other recharging mechanism becomes available, the battery is automatically recharged until either the AC power source is connected or the battery is fully charged.
An option function can be included to issue a warning message to the central facility when the power drops below a pre-determined threshold. In this case, if the recharging sources successfully recharge battery 82 back to an acceptable level, another message will be issued to notify the central facility to erase the low power alert.
A communication control interface 106 couples CPU 100 with communication module 14. When the system 10 is in the dormant mode, no communication is needed. As soon as system 10 is activated by wakeup sensor 80, system 10 starts to establish communication. The function of communication control interface 106 determines the most cost-effective, available mode of communication. If local RF is available, the communication between system 10 and the central facility uses the RF pursuant to control by the processor's 100. Otherwise, system 10 will try to establish communication through any of the multi-band cellular networks or wireless data networks. Only if none of the above communication modes can be successfully made, will system 10 activate the satellite communication channel. While the communication is established at any level, system 10 continues to detect the communication at a lower level, and switch to a lower level if it becomes available pursuant to the processor module 20.
A location control interface 108 couples CPU 100 with location module 12. The current location of system 10 is always registered in processor module 20. When system 10 was initialized, the initial location is registered immediately. Whenever a valid location update is received, either from GPS, from RF, or calculated by the built-in motion detector 32, the current location is updated and saved in memory 102. Whenever the system detects a valid GPS signal, the current location is also updated. At any moment, location control keeps the current location to be sent to the central facility upon request.
Thus, it can now be summarized that processor module 20 controls the flow of data throughout system 10, manages the calculation of location, and determines the transmission of data to the available communication mode. Processor module 20 receives input of location information from location module 12 and keeps tracks of the current position, manipulates the input and output of data elements thought the communication mode, and issues commands to control the power use and system shutdown. Processor module 20 saves all the operational parameters in storage memory 102, and retrieves current position from storage 102 upon system requests.
The system 10 employs a combination of long-range and short-range asset location systems, such as a GPS-based system combined with an RF-based system. The short-range system regularly activates itself, or is remotely polled, to determine if the surgical asset is within range of the short-range transceivers, and the long-range system is activated to determine the location of the surgical asset when it is outside the range of the short-range transceivers. In at least some embodiments, the surgical asset is equipped with both RFID and GPS-based receiving equipment. The receiving equipment may be part of a stand alone unit or part of a transceiver. In other embodiments, the surgical asset is equipped with radio-wave transmission equipment and microwave transmission equipment. Again, the transmission equipment may be part of a stand alone unit or part of a transceiver.
One particular embodiment of the system 10 uses multiple wireless technologies (RFID, GPS, CDMA, etc.) in single tag to facilitate asset tracking and locating, and is particularly advantageous in such areas as manufacturing plants, during delivery to healthcare facilities, and while stored within the healthcare facility.
In yet another embodiment, the system 10 includes a medical device readiness module as is explained in greater detail below.
In some embodiments, the system 10 utilizes the real-time location system (RTLS). RTLS does not require line-of-sight (indoor/outdoor) but utilizes RF or RFID tags. These tags may conform to the ANSI 371/INCITS 371 standards, known to those of skill in the art, including transponder tag, antennae, and transceiver with decoder or some other similar standard. This type of system is typically capable of XY location accuracy within 3 to 300 meters. Of course, more readers enable greater accuracy.
In some embodiments, the initial RF tag is attached to the surgical asset during beginning of assembly. Later, the RF tag is integrated into the GPS system on the asset. In this way, the surgical asset is trackable throughout plant grounds (indoor and outdoor), and the system facilitates finding the asset (warehouse, during delivery, at the hospital, etc.) as needed. A locator, such as a handheld PDA, can be used to locate the surgical asset. The same RTLS infrastructure can be used for facility management, surgical planning, warehouse management, distribution, logistics, etc.
The RTLS/RFID tags can be programmed to emit a signal periodically, such as every several hours, as selected by the operator, and when in the presence of a reader would update the database with the asset's location.
Location application server 308 includes software having a triangulation algorithm, as known to those of skill in the art, for locating the surgical asset 304 within the area served by antennas 306. Location application server 308 communicates over network 310, which can be the Internet or another public or private network, with central location server 312. Typically, there also may be one or more firewalls, not shown, through which the communications are made. Location information may be encrypted and secure at all times during transmission and storage. Central location server 312 includes a database that stores the last known location of each surgical asset. External system 314 is connected to communicate with central location server 312, so that the asset location information can be used for any appropriate purpose.
Additionally, a GPS compliant system is attached to the surgical asset. Assisted GPS utilizes cellular network to reduce GPS search time to seconds versus minutes. Special software, known to those of skill in the art, is required for both transponder and transceiver/decoder. The GPS system is typically capable of XY location accuracy within 5 to 30 meters.
Location application server 428 communicates over network 410, which can be the Internet or another public or private network, with central location server 412. Typically, there also may be one or more firewalls, not shown, through which the communications are made. Location information may be encrypted and secure at all times during transmission and storage. Central location server 412 includes a database that stores the last known location of each surgical asset. External system 414 is connected to communicate with central location server 412, so that the asset location information can be used for any appropriate purpose.
In the GPS-based system, the location application server 428 may perform asset location polling. Unsold surgical assets, unshipped surgical assets or other surgical assets for which up-to-date location information is needed can be polled when their last known location is a selected number of hours old. Asset location polling can be tied to surgical asset event status (build, delivered, sold, particular surgical set required, etc.).
Location application server 528 communicates over network 510, which can be the Internet or another public or private network, with central location server 512. Typically, there also may be one or more firewalls, not shown, through which the communications are made. Location information may be encrypted and secure at all times during transmission and storage. Central location server 512 includes a database that stores the last known location of each surgical asset.
An identifier tag, such as an RFID/RTLS tag, is installed also in surgical asset 504. This tag communicates with antennas 506, which are in turn connected to communicate with location application server 508. While three representative antennas 506 are shown, a typical installation includes one or more antennas, so that an RTLS tag can be located anywhere within the covered property. The tags can be set to broadcast an asset identification number, or other asset identifier, at set intervals (e.g., every 30 minutes, every hour, etc.).
Location application server 508 includes software having a triangulation algorithm, as known to those of skill in the art, for locating the surgical asset 504 within the area served by antennas 506. Location application server 508 communicates over network 510, which can be the Internet or another public or private network, with central location server 512. Typically, there also may be one or more firewalls, not shown, through which the communications are made. Location information may be encrypted and secure at all times during transmission and storage. External system 514 is connected to communicate with central location server 512, so that the asset location information can be used for any appropriate purpose. The asset location server 508 may conduct asset location polling at discrete intervals.
The combination system allows surgical assets to be tracked in transit from the assembly plant to their end destination via GPS. Surgical assets can then be tracked by GPS on a national scale or by RF once they reach suitably-equipped locations, such as a hospital or other healthcare facility, point-of-assembly, warehouse, etc.
Some specific advantages of a system as described include tying GPS and RTLS together to allow for “smart” connections utilizing the lower cost medium when available. The tag can augment and leverage GPS systems. RTLS can later be expanded to locate instruments, instrument trays, instrument tray cases, etc. at hospitals, surgical centers, and other healthcare facilities.
Mobile surgical asset 710 also includes a communications transceiver 752 functionally independent from navigation set 750. If the navigation set comprises a transceiver, then the function of transceiver 752 can be performed by the transceiver of navigation set 750. Both, transceiver 752 and navigation set 750 are activated by a controller 758 which, in turn, is responsive to signals from a clock module 760. Transceiver 752 is capable of transmitting the asset location data by way of communication link 714 (
A low power, short distance radio link permits joining the nearby mobile surgical assets in a network to conserve power and maintain high reliability and functionality of such network. The surgical asset 710 may include one or more power sources 762 (which may be charged from an array of solar cells 766 through a charging circuit 764), GPS receivers 750, communications transceivers 752, and various surgical asset sensors 768A-768D. As examples, the surgical asset sensor 768 may be a temperature sensor, pressure sensor, strain gauge, limit switch, or instrument readiness circuit or switch, which will be explained in greater detail below. Each surgical asset includes a low power local transceiver 770 and a microprocessor 772. Microprocessor 772 is interfaced to all of the other elements of the surgical asset and has control over them. Transceiver 770 may be a commercially available spread spectrum transceiver such as those currently utilized in wireless local area networks. Spread spectrum transceiver 770 is equipped with its own low profile antenna 774.
Forward and reverse (surgical asset to central station) channels are used for communication between the surgical assets and the central station. In the protocol depicted below, flags that occur in the data are not used. This is ensured by using bit stuffing (or bit escaping). This increases the traffic load by a factor of approximately 63/62. An exemplary protocol for the forward channel frame structure is as follows:
In the above frame structure, F is an 8-bit flag. ADDR is an identification number of an addressed unit comprising 20 bits, 19 for the address with one bit reserved. FC/C is a frame counter for forward control link. A first bit denotes presence of the counter. A zero indicates no counter is present, while a one indicates that the next twenty bits are the counter bits. C is a control field which specifies the message type; e.g., a zero specifies a polling message and it is understood that no control field bits follow a zero, while a one specifies another type message specified in the next three bits.
DATA specifies the future time for the addressed unit to start its response transmission. This could be keyed to GPS time or it could be keyed in another way, such as to a counter based on the end flag epoch of a correctly received forward control frame. CHNL is the narrow band channel on which the addressed unit will respond. The channel field contains eight bits. Bits 1-7 are used to specify the channel number. Bit 8 is reserved. It is normally zero. If the system is to expand beyond 128 channels, then bit eight can be set to a one and the field interpreted as extended by a present number of bits. EC is an error detection code formed over the ADDR through CHNL fields.
As a quick check on the feasibility of such control system, assume that there are A assets, that the forward channel is running in just the sequential polling mode, that the FC/C counter is not used, that the DATA field is twenty bits, that the CHNL field is eight bits, and that the error checking field is sixteen bits long. The time in minutes, T, to complete a sequential polling, is then approximately:
assuming that ten kilobits per second can be passed over the forward control link. If A is on the order of 100,000, then T is on the order of fifteen minutes.
The surgical asset receivers need not continuously monitor the forward control link; rather, they can extrapolate to the next minimum time to the repeat of interrogation and listen at just before that epoch. If there has been much traffic other than polling, the surgical asset receiver can determine, from what the polling number is, whether to stay on or go back into standby or “sleep” mode until just before the minimum time to poll from that point.
An exemplary protocol for the return channel has the following frame structure:
SYNC ID C DATA FEC EC F
In the above frame structure, SYNC is a synchronization preamble to establish carrier synchronization, symbol boundaries, and epoch via a unique word of low autocorrelation sidelobes. ID is the asset tracker identification field. C is the control field which designates message: type. If the first bit is zero, then the message is conveying length in response to a polling message on the forward link. The length of the message is coded in binary from MSB to LSB (most significant bit to least significant bit). The number of bits need not be fixed as the number can be determined by counting backwards from the ending flag. FEC is an optional forward error correcting field. It is not present if the first bit is zero. EC is an error detection code formed over the ID field through the FEC field.
The protocol functions as illustrated in the flow diagram of
The process begins by the central station polling the surgical assets in the narrow band forward channel at step 801. The surgical assets answer on the narrow band return or service channel in fixed frame format at their assigned slot at step 802. The central station receives the responses from the surgical assets at step 803 and determines which of the surgical assets is prepared to transmit data and how much data those surgical assets will transmit. Based on the list generated at step 803 regarding the amount of data to be sent and by which surgical assets, the central station assigns a report-back channel and a time to begin transmission. The scheduled time and report-back channel are transmitted to the surgical assets on the forward channel at step 804. There may be a plurality of narrow band report-back channels that may be appropriately multiplexed among the surgical assets transmitting data to the central station to conserve frequency spectra. When a scheduled time for report-back by a surgical asset occurs as determined at decision step 805, the central station monitors the assigned report-back channel at step 806. If the central station must pause or wait before proceeding with scheduling, it may send repeated flags on the forward channel as an accepted inter-frame flag-fill mode. After each surgical asset in the list reports, a check is made at decision step 807 to determine if all the surgical assets which are on the list to report have reported and, if not, the process loops back to decision step 805. When all data to be sent have been received, the process ends.
Referring initially to
In some embodiments, RFID tags 1217 and 1218 are attached to the medical instruments 1216 by an adhesive substance such as glue, paste, gum, epoxy resin, tape, bonding agent, or any other type of adhesive that will attach the RFID tags 1217 and 1218 to the medical instrument 1216. In other embodiments, RFID tags 1217 and 1218 are attached to the medical instruments 1216 by a mechanical device such as a clip, fastener, clasp, pin, screw, or any other device that will mechanically associate an RFID tag to a medical instrument. In other embodiments, RFID tags 1217 and 1218 may be attached to the medical instruments 1216 by molding or otherwise, including during manufacture of medical instruments 6 or otherwise.
Referring again to
Referring now to
RFID tags 1217 and 1218 of certain embodiments of the invention, associated with medical instruments 1216 and located inside the sterilization case 1210, have the capability of transmitting or responding with encoded data or a signature when they are interrogated by a reader 1212. In some embodiments, the RFID tags are passive, in that they do not contain an independent energy source but must depend on the radio frequency signal from the reader to provide its response or signature. An alternative embodiment includes active RFID tags that contain an independent energy source, such as a battery or other energy sources, so that the RFID tag can actively transmit a signal or information.
The reader 1212 is shown as a handheld device capable of transmitting a signal via radio frequency to the RFID tags 1217 and 1218 and receiving encoded data or RFID tag signatures via radio frequency from the RFID tags 1217 and 1218. The reader 1212 also has the capability of outputting the received data onto a viewable interface or to a computer via electrical or wireless connection. It should be understood by those with skill in the art that the reader 1212 may take any stationary or movable form with the function of reading RFID tags. For example, in an alternative embodiment the reader 1212 is a mat and the sterilization case 1210 containing the medical instruments 1216, may be placed on the mat. The reader 1212 then reads the RFID tags attached to the medical devices.
When the sterilization case 1210 is made from steel, aluminum, titanium, or any type of metal, radio frequency communication between an RFID tag 1217 and 1218 and a reader 1216 may be greatly attenuated and the presence of metal may prevent all communication. The sterilization case, however, may be modified to allow radio frequency communication between the RFID tags 1217 and 1218 and reader 1212. Modifications to the sterilization case may include openings 12133 such as holes, slits, or any other type and size of opening in at least one side of the sterilization case. In other embodiments the sterilization case 1210 may be made from a material, such as plastic, paper products, wood, cloth, vinyl, metal or leather, that allows radio frequency signals to enter and leave the case. In still other embodiments, a master RFID tag or reader may be attached to the outside of the sterilization case to collect information from inside the case and communicate the information to an external reader.
Referring now to
In certain embodiments, the type of data transmitted by the RFID tags 1217 and 1218 and case RFID tag 1215 to the reader 1212 may include the identification of the medical instruments 1216 to which the RFID tags 1217 and 1218 are attached, the contents of the entire sterilization case 1210, the surgical technique associated with a particular medical instrument 1216 or group of medical instruments contained within the sterilization case 1210, surgical implants with which the instrument 1216 is to be used, the manufacturing history of a particular medical instrument 1216, how many times the instrument 1216 has been sterilized, or any other relevant data associated with the instruments, group of instruments, or case. Alternatively, the RFID tags 1217 and 1218 may respond with a signal or signature that keys or correlates to such information in a database in the computer system or on a network such as the Internet or a local network. One may see that a number of different types of data may be conveyed with or keyed to information conveyed using RFID tags 1217 and 1218 and case RFID tag 1215. In the embodiments depicted in
Referring now to
Referring now to
Referring again to
Referring now to
In an alternative embodiment, the reader 1212 includes a database and viewable interface. The reader 1212 compares the encoded data with the database and the results are viewable on the interface.
A schematic representation of the sterilization case 1400 is shown in
The identification of which component is in the sterilization case is dependent upon knowing the equation for the total resistance of several resistors in parallel. For two resistors, R1 and R2 in parallel, the total resistance is:
R=R1×R2/(R1+R2) Equation 1
For three resistors, R1, R2 and R3 in parallel, the total resistance is (omitting the multiplication signs for clarity):
R=R1×R2×R3/(R1 R2+R1 R3+R2 R3) Equation 2
The general equation for n resistors in parallel is:
1/R=1/R1+1/R2+1/R3 . . . +1/Rn−1+1/Rn Equation 3
By a careful choice of R1, R2, etc., the knowledge of R will uniquely identify which components are in the tray. Let the resistors R1 to R4 in
The wires in the electrical circuit go through the holders for each of the components, whether the holders are foam or something more rigid. If the battery and indicator were also in the foam or equivalent material, the sterilization case itself would not have to be altered in any way. However, it may be beneficial to fix the battery and/or indicator to the sterilization case.
More complex variations of the technology for identifying medical instruments in a sealed sterilization case are described below in
Alternatively, the circuit may be a complex circuit that has a “yes/no” indicator showing whether the case is correctly filled. If “no,” then a handheld device containing a DSP is plugged into the case (via a socket on the outside) to carry out a more involved analysis to determine why the case is not correctly filled. It is a bit like the warning light in a car coming on, so the owner drives to the garage where a computer does a series of diagnostic tests. In principle, one handheld device could contain diagnostic software for all instrument cases, and also contact the medical device manufacturer with the relevant information.
The electronic sterilization case may be powered using an internal sterilizable battery or an external battery which could be attached to the outside of the case when the contents of the sterilization case need to be read. The main constraint to powering the system using this approach is that the user would have to read through the wrapping after the set had been sterilized. Alternatively, it is possible to inductively power the circuit in the same way that passive RFID tags are powered. In this situation, no battery is required. It is also possible that the output from the indicator is saved on an active RFID tag on the outside of the tray. Thus, it is possible for the circuit to tell the tag what is in the tray, and for the tag to tell the RFID reader, and therefore the outside world, what is in the tray. This gets around the problem associated with some RFID systems of not being about to detect through or very close to metals.
The electronic sterilization case can be connected to a reader 2100 via a plug-in or a wireless connection. In the embodiment depicted in
The reader 2100 powers the sterilization case using an on-board battery and is electrically linked via the input/output (I/O) connection 2116. A digital signal processor (DSP) 2114 located in the reader processes the electrical signal received from the source (sterilization case) into a format that can be easily interpreted by the end user. The information is then displayed on a screen 2118 in three formats (a) digital, (b) visual or (c) text, which is then selected by the end user. The reader interrogates the tray to determine whether there are either missing instruments or incorrectly placed instruments. This information is displayed on the screen of a personal device assistant (PDA) which can be used by a member of the hospital staff. The current data set generated is compared to a set of signals stored in a database, which are either contained in the reader or a remote computer system. A software program informs the user if the contents of the case are present, enabling them to proceed with the autoclaving of the sterilization case. The user can verify this information by repeating the task. In the event where the displayed results indicate that some instruments are missing, the software could alert the hospital staff to search for other cases which could be quickly selected and read to determine if they contain all the necessary instruments for a particular surgical procedure. In this situation, an appropriate sterilization case can be selected and its sealed wrap broken for a particular procedure.
The user may utilize the results displayed on the interface to determine whether all necessary instruments for a particular surgical procedure are contained within the packet, if some necessary instruments are missing to locate them in another instrument packet, or to locate a packet that contains all necessary instruments.
The reader 2322 may sense the instrument tray and/or medical device to read a component specific alphanumeric string of characters which identifies the instrument tray or medical device. The character string is passed on to the computing device 2316, and the computing device 2316 then retrieves one or more files relating to the character string. Thus, the computing device 2316 retrieves files related to the particular tray or device. The file may be any type of media file, such as a video, audio, or text file. For example, the retrieved file may be a surgical technique that instructs the user on the steps for performing a particular surgery. Thereafter, the computing device 2316 executes the files, which may include displaying a video, displaying text, playing an audio, or some combination thereof.
In the case of an RFID reader, the RFID reader reads a unique alphanumeric string of characters from the RFID chip on the instrument tray or medical device. This character string is associated with a specific implant system. The computing device then accesses its hard drive memory files or the server to retrieve stored files associated with the character string.
In one particular embodiment, there is an area around the patient 2300 that defines a surgical field. The surgical field may be defined by placing emitters (not shown) in strategic locations around the table 2308. As examples, the emitters may be optical emitters or radiation emitters. In this embodiment, the reader 2322 can sense when instrument trays and/or medical devices enter the surgical field. Thus, as the particular instrument tray or medical device enters the surgical field, the reader 2322 senses the item and sends the character string to the computing device 2316. The computing device 2316 automatically retrieves the relevant file and executes the file. Of course, the computing device may retrieve multiple files relating to one particular surgical implant system or repeat the process for individual components. This embodiment is particularly useful for orthopaedic surgery as the surgeon may be presented with relevant information contemporaneously with the surgical step being performed.
One example in accordance with the present invention is as follows. In preparation for a surgical procedure, such as a total knee replacement, members of medical device central processing sterilize the medical instruments to be used. A variety of medical instruments may be sterilized, such as a cutting block, fin stem punch, femoral trial, and patella clamp.
Prior to sterilization, a passive RFID tag, such as those manufactured or supplied by Danby, TTP, QinetiQ, or Precimed may be attached to each medical instrument. In some embodiments, the tag may be a combined RFID/GPS tag available from QinetiQ. The RFID tag is preferably attached by an instrument management company to the medical instruments with an epoxy adhesive, but may be attached immediately prior to sterilization by a clip or some other mechanical method.
The medical instruments, with an RFID tag attached to each one, are placed inside a sterilization case, such as model number 7112-9401/9402/9400 manufactured by Smith & Nephew, Inc. The sterilization case is wrapped in a plastic wrap, such as Kimberly-Clark 600 sterilization pouch or sterilization wrapper, and the wrap is then sealed.
The sealed sterilization case containing the medical instruments is placed in the sterilization pouch and the pouch is sealed. The completed assembly is then placed into an autoclave and subjected to a medical autoclave sterilization process. The sterilization case is removed then from the autoclave and placed on a shelf.
The wrapped instrument cases are taken to a central storage location. When the case is scheduled, they are taken to a staging area or up to the operating room. Just prior to surgery, a medical instrument sales representative, hospital employee, or nurse scans the instrument packets in central processing, a staging area, or in the operating room with an RFID reader. The reader is preferably a handheld reader, but may also be a mat reader, a stationary reader, or any other reader disclosed herein. In a particularly preferred embodiment, the reader is handheld and is scanned over the wrapped sterilization case prior to the sealed outer wrap being broken.
The information obtained from the RFID tag is sent, through wireless or wired connection, to a computer or handheld computing device, such as a Hewlet-Packard iPAQ or a network. In an alternative embodiment, the information is displaced on a screen located on the reader. The output may show, for example, a sterilization case list, the contents of the case, the part numbers necessary for a procedure, which instruments are missing, or any information relevant to medical instrument inventory and management. If the interface indicates that all instruments necessary for the procedure are present, then the sealed plastic wrap is broken, the instruments are removed from the sterilization case, and laid on a tray table in the operating room. If the interface indicates that all instruments necessary for the procedure are present, then the person scanning would notify someone assisting in the surgery that the packet is not complete and that another packet is read to supplement or replace the first packet.
There are multiple users of this system. They include but are not limited to hospital staff (nurses, doctors, sterilization techs, etc.), sales representatives (associates), distributors, and manufacturers. The invention provides the users with a system that allows them to locate certain items as well as obtain additional information. Types of items can include instruments, instrument sets, implants, implant sets, and capital equipment. Types of information that can be retrieved include but are not limited to history of use, item sterilization status, who handled the item last, whether an instrument is missing from a set, and whether inventory of a particular item is low.
The tracking system operates by communicating between devices, such as instruments and trays or a tray and the system tracker. To track the location of an instrument, implant or other inventory device, a user must interface with a computer system. The system is then able to identify the location of the device and can provide additional information about the device. This additional information is data that is stored on the RF tag as well as exits in a history file managed by the tracking system which the user can review.
To determine if a set is ready for surgery the user can view the display on the set which when prompted identifies whether the set contains the pertinent devices to perform the surgery or not. If not, the display can show what devices are missing. This can be achieved by having an exciter housed in the set, and when prompted by the user it sends a signal out that will generate a response from all devices within the set. The exciter is part of a computer system that also contains a receiver that will read these responses. From these responses, the system can determine if all of the required devices are currently housed in the set or not.
The invention for providing the surgeon with the surgical technique also uses RFID recognition. An RFID tag is rigidly affixed to the instruments, implants, and devices. Located in the operating room is a computer system that is integrated with an exciter and a receiver. When prompted by the user, the computer sends a signal via the exciter that will generate a response signal. This response signal is then received by the receiver and read into the computer. This signal identifies the particular instrument or implant. This information allows the computer to pull up a written or video technique showing how to use the instrument or implant. It also can show the user information on how to perform the entire surgical technique using the system.
A read/writeable RF tag is permanently affixed to instruments, implants, and devices. These tags can be either passive or active. Both tag types can contain multiple types of information such as manufacturer data, instrument name, quality control number, instructions for use, expiration date, last date used, last sterilization method and date, and the last person to handle the device.
An exciter is used when information is needed to be obtained from an instrument, implant, or device that contains a passive tag. The passive tags when excited by an exciter signal will emit an RF response signal. These exciters are used in conjunction with a receiver and a computer that controls the exciter's activities as well as processes the received signals. These computers can be connected to an area network. These exciter/receiver systems may be located in various areas such that they can communicate with the desired instrument, implant, or device. An example would be in an OR, a central supply facility, manufacturing facility, or on an instrument case.
A global and local system is set-up to allow users such as manufacturers, vendors, sales representatives, surgical techs, or surgeons to determine information about a particular device, instrument set, or implant set.
One example includes a local user attempting to locate a specific instrument set within a hospital. This person can access a computer system that using RF communication as previously described can determine the exact location of the instrument set within the hospital as well as provide other pertinent information (sterility status, expiration date, user instructions, etc.). This computer system could be an integrated desktop, laptop, or PDA.
An alternate embodiment of this invention would be a handheld device that will project a light source onto the device which the user is attempting to locate. This would be helpful when one is standing a room full of instrument sets and is trying to find a needle in the haystack.
Instrument tracking can also occur at a larger level. This includes distributors trying to locate where a specific instrument set is in the world. This concept is similar to the tracking done by shipping companies except that it is not tracking at ports only, but rather provides real-time location information. Another use is that of representatives or manufacturers attempting to determine the usage or activity of a set. The system can detect movement of the set and will track and store this information which can be accessed by the user for analysis.
Another facet of the invention allows the user(s) to determine if an instrument set is ready for use in surgery. The set itself would contain an exciter/receiver computer system that would verify that all needed instruments, implants, or devices are in the set by reading and evaluating all response emissions. The user can control what criteria is used to determine what are “needed”. This information can be displayed directly on a display screen affixed to the set and/or can be displayed using a separate computer system. An example would be a display screen showing a green box signifying that the set is ready for use in surgery as well as showing the date of the last sterilization procedure the set has undergone. Or the display could show a red box signifying that it is not ready for surgery and provide a list of instruments that are missing from the set.
This invention also allows for a user to access the surgical technique for an instrument, implant, device, or an entire system using a computer. This is accomplished by having a computer system that is integrated with an exciter and receiver. This system can communicate with a device that contains an RFID tag. The tag will contain information regarding the surgical technique and this information will be displayed on the screen. Another embodiment would be that the product information read from the instrument would be used by the computer to access the technique material and then display it. This could include a video and/or the written surgical technique. This is a useful tool when operating with a new instrument/implant or one seldom used.
This invention includes the ability for a hospital or an account manager to track and manage the inventory of a hospital. By tracking instruments, implants, and other devices, the automated system can determine if the inventory level for any item has reached a level where the item stock needs to be replenished. This would include for example the system noticing that a hospital has only two implants of a certain size left. This would automatically prompt the system to send out a replenishment order request. This benefits the hospital by never running out of a needed instrument or implant, as well as to the rep who no longer has to spend time managing inventory.
As various modifications could be made to the exemplary embodiments, as described above with reference to the corresponding illustrations, without departing from the scope of the invention, it is intended that all matter contained in the foregoing description and shown in the accompanying drawings shall be interpreted as illustrative rather than limiting. Thus, the breadth and scope of the present invention should not be limited by any of the above-described exemplary embodiments, but should be defined only in accordance with the following claims appended hereto and their equivalents.
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|U.S. Classification||340/539.1, 340/539.13, 340/539.12, 340/572.1|
|Cooperative Classification||A61B90/90, A61B90/98|
|Aug 27, 2007||AS||Assignment|
Owner name: SMITH & NEPHEW, INC., TENNESSEE
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:AUSTIN, GENE EDWARD;GRANVILLE, NICHOLAS W.;HULEN, MARK E.;AND OTHERS;REEL/FRAME:019748/0897;SIGNING DATES FROM 20070418 TO 20070817
|Sep 12, 2012||FPAY||Fee payment|
Year of fee payment: 4
|Sep 29, 2016||FPAY||Fee payment|
Year of fee payment: 8